A. CASES OF SECONDARY INFLAMMATION, ACCOMPANIED BY MORTIFICATION OF THE SKIN.
Case i. William Ford, 33, an apparently healthy man, was seized with the symptom of strangulated hernia, at Harrow, December 28th. He was bled in both arms; but, as the hernia remained unreduced, he was sent to town, in a state of considerable restlessness and suffering. During his journey, the hernia returned of its own accord. He left quite relieved, and remained well till the 31st, when he had a rigor. On the 1st of February, there was a considerable degree of febrile excitement, and the anterior part of the left arm was red, swollen, and painful upon pressure. The tenderness and pain soon extended up the arm, in the course of the cephalic vein: the redness assumed the character of erysipelas. On the 3rd, he suffered from sickness, the matter vomited being green and acid. He had two severe rigors, followed by great heat of skin, and a quick full pulse. The orifice in the left arm discharged a thin serous fluid. On the 4th, he complained of stiffness in the right arm; also of being very feeble and faint. 5th. Wandered much during the night. The right arm was a good deal swollen about the end of the elbow-joint, and presented a patch of a bright red colour above the condyle. The pulse was weak and tremulous; motions of the hands were occasionally observed. He complained of pain in the ring-finger of the right hand, and in the ball of the right great toe. The skin, in both these situations, had assumed a red appearance. 6th. Was delirious during the greater part of the night; countenance expressive of much anxiety; pulse very weak; tongue covered by a brown dry fur; profuse perspiration; complained of severe pain in the calves of his legs. He died during the following night.
Post-mortem appearances. A small deposit of thick pus was found on the external surface of the left cephalic vein. The blood was coagulated in its cavity, its coats were thickened, and its lining membrane appeared very red. This redness could be traced, though in a less degree, through the whole extent of the vena innominata. On the right side, the cellular tissue, both above and below the elbow-joint, was greatly distended with serum. The cephalic vein of the right arm presented marks of having been inflamed; but not nearly to the same extent as upon the opposite side. The joints in which pain had been experienced during life, were distended with turbid pus; deposits of pus were also found in the anterior mediastinum, and between the œsophagus and trachea. A large gangrenous spot was observed in the skin of the calf of the right leg. The subjacent cellular tissue was much distended with serum.
Case ii. Richard Mason had a small cancerous tumour removed from the lower lip. The operation was performed in the usual way, and the wound appeared to heal by the first intention; a small abscess, however, followed by some ulceration, subsequently appeared in the neighbourhood of the cicatrix. Nine days after the operation, he complained of sore throat and general uneasiness, and three days afterwards he was seized with rigors, followed by cold perspiration and coma.
Post-mortem appearances. A small deposit of matter was found, situated beneath the fascia of the left thigh. The synovial membrane of the left knee was highly inflamed, and contained a large quantity of pus. On the right side, the skin of the whole inferior extremity presented a dark livid appearance, with the exception of that situated upon the fore part of the thigh. The same dark colour was observed in the muscles of the limb, which were infiltrated with blood and serum. The arteries and veins were discoloured, but in other respects presented nothing remarkable. It was ascertained, that, two years previously, this patient had suffered from diabetes; and upon examining the urine found in the bladder, it was found to contain sugar.
Case iii. Jane Thornton, æt. 32, came under treatment on the 22nd of March. A week previously, her right ancle had become red and painful, and inflammation subsequently extended up the inner side of the leg. When first seen, she was evidently much out of health, although no one organ could be said to be particularly affected. On the 28th of March, she was attacked with severe rigors, and experienced pains in different parts of her limbs: the rigors were repeated for several days in succession. The inflammation of the leg now entirely disappeared, and she complained of pain in the right knee, which was slightly swollen. On the 31st, her bowels became much relaxed; there was great general depression, and much nervous agitation. Both knees were swollen. The general symptoms now became somewhat relieved; but on the 4th April, she was attacked with vomiting, which recurred frequently during the day, and was accompanied with great depression, and severe pain in the epigastrium. On the 5th, the sickness continued, apparently quite uninfluenced by any remedies. She passed considerable quantities of blood by stool: her countenance presented a dusky yellow hue: the pulse was excited, without power, and the sense of depression was greatly increased. On the 7th, the vomiting still continued, and she still passed blood by stool. Some spots of a dark purple colour now made their appearance upon her face. The hands both became slightly swollen; and upon the right one, some small, dark, livid spots, similar to those upon the face, made their appearance. She was much troubled with hiccough. On the 9th, the countenance was very anxious, the complexion more sallow: some more livid spots appeared upon the face and cheeks. The right hand and arm were swollen and painful: some fresh livid spots appeared, upon the knuckles. Complained much of faintness: had extreme debility with occasional hiccough: pulse extremely weak: the surface of the body was covered with cold perspiration. The sickness had entirely ceased, and there was no blood in the motions: the tongue was rather dry in the centre, but tolerably clean. 10th. She wandered slightly during the night, and vomited once: some blood again appeared in the motions; the right hand and arm were less swollen. 11th. The countenance was anxious, the pulse about 90, and intermitting irregularly. The vomiting recurred several times. The livid spots on the right hand had not increased in size, but appeared like distinct small black superficial sloughs of the skin; these all scabbed off, without suppuration. 12th. The pain and swelling of the arm had nearly subsided. The bowels acted very freely with the aid of medicine, and she expressed herself much relieved. From this time the patient slowly but gradually improved, with one or two slight intermissions, till the beginning of May, when she again complained of pain at the inner part of the right arm, above the elbow. Some hardness could here be felt in the course of the basilic vein. Some small collections of matter were now deposited upon the back of the right hand, resembling, in some respects, the eruption of confluent small-pox. On May 11th, she had regained much of her strength, but still felt some pain in the elbow upon motion. She also complained of the joints of one of her fingers. She now left London for change of air.
B. The following Table is formed of Cases taken consecutively during One Year.
C. Case xxvii. George Burton, æt. 22, a stout navigator, was first seen September 18th, 1848. He had an enormous slough of the skin and cellular membrane, covering the lower part of the abdomen on the right side. He gave a most imperfect history of himself, and seemed frequently incapable of comprehending the questions which were put to him. The skin was hot and dry, the pulse 130. For several days, he remained in the same apathetic condition. The bowels were particularly obstinate, and the purgative medicines which were administered produced no effect whatever.
When the slough separated, the surface of the external oblique muscle was left as clean as if recently dissected. The skin was undermined for some extent, and no attempt was apparently being made to limit the progress of the disease, by the effusion of lymph. Fresh portions of cellular tissue consequently became affected, and the whole surface ultimately exposed was full six inches in diameter. Sept. 25th. Complained of some pain in the chest and upper part of the abdomen; has a constant short cough; perspires very freely. 26th. The pulse has become weaker, but remains of the same frequency (130). It communicates a peculiar jerking sensation to the finger. 28th. Pulse 96, weaker; slight diarrhœa; he vomited several times during the day. 29th. Restless, with delirium. 30th. Passed another restless night, but became better in the course of the day; his appetite returned. Oct. 5th. His appetite again failed; complained of a sense of distension in the abdomen. 8th. An abscess was discovered at the lower and back part of the right leg; the skin over this presented various shades of yellow and brown, giving the appearance of having been extensively bruised. About two ounces of discoloured pus were evacuated, together with a considerable quantity of grumous blood. 10th. Has much improved since the last report; the wound discharges dark semi-coagulated blood. 13th. A second abscess now presented itself in the same leg, and the skin covering it assumed the same discoloured appearance as in the first instance. When opened, it discharged dark-coloured semi-coagulated blood with the matter. He now rapidly improved in health, and at length perfectly recovered.
Case xxviii. Samuel Todd, æt. 58, fell from a wagon fifteen miles from town, and was brought up in an open cart, during a sharp frost. There was a compound fracture of the left leg. Two days afterwards, he suffered from cellular inflammation around the wound. On the 24th day, he had a slight rigor, and complained of slight stiffness in the right shoulder. He ate and drank well till within two days of his death, which took place on the thirty-fourth day.
Post-mortem appearances. Both lungs contained secondary abscesses, in various stages of formation. The left external iliac and common femoral veins were blocked up with firm coagula, and confined by these was a quantity of purulent-looking fluid; an adherent layer could, for some distance, be peeled off the internal surface of these vessels.
Case xxix. James Howard, æt. 33, had a small abscess in the dorsum of the right foot, which was followed by inflammation of the absorbents; abscesses subsequently formed in the right thigh and groin. Two months after the first appearance of the abscess on his foot, he was seized with rigors, vomiting, and profuse perspiration. He complained also of pain in the lower part of the left lung, and it was said that the respiratory murmur was deficient in this situation. He died on the 23rd day from the appearance of the symptoms of the secondary affection.
Post-mortem appearances. The skin and conjunctivæ were of a light yellow colour; there were incisions in the right groin. In the cavity of the right pleura, were some patches of recently effused lymph, of a yellowish colour. In the lower lobe of the right lung, were several patches of secondary deposit; these were found in different stages of their formation, and some of them were of considerable size; some of the pulmonary veins, in the neighbourhood of those which had suppurated, were found to contain a fluid resembling pus. On the left side was a small abscess, under the pleura costalis. The liver was healthy in structure, rather larger than usual. Kidneys healthy. The veins in the groin presented a healthy appearance.
Case xxx. A gentleman was operated upon for hæmorrhoidal tumours in the usual manner, and died shortly afterwards, with effusion of bloody serum into one of the pleural cavities. The only peculiarity that could be detected in the appearance of the rectum was, that the blood was still fluid in one of the largest veins. This vein led directly to an ulcer produced by the operation; and, even at its extremity, it contained no appearance of coagulum.